Training and Toolkit Resources to Support Implementation of a Community Pharmacy Fall Prevention Service

Community pharmacies are an ideal setting to manage high-risk medications and screen older adults at risk for falls. Appropriate training and resources are needed to successfully implement services in this setting. The purpose of this paper is to identify the key training, tools, and resources to support implementation of fall prevention services. The service was implemented in a network of community pharmacies located in North Carolina. Pharmacies were provided with onboard and longitudinal training, and a project coach. A toolkit contained resources to collect medication information, identify high-risk medications, develop and share recommendations with prescribers, market the service, and educate patients. Project champions at each pharmacy received a nine-question, web-based survey (Qualtrics) to identify usefulness of the training and resources. The quantitative data were analyzed using descriptive statistics. Thirty-one community pharmacies implemented the service. Twenty-three project champions (74%) completed the post-intervention survey. Comprehensive onboard training was rated as more useful than longitudinal training. Resources to identify high-risk medications, develop recommendations, and share recommendations with prescribers were considered most useful. By providing appropriate training and resources to support fall prevention services, community pharmacists can improve patient care as part of their routine workflow.

. Implementation training and resources.

STEP 1: ONBOARD TRAINING
TOOLKIT REVIEW 66-page toolkit mailed to pharmacies three weeks prior to live implementation. Pharmacy project champions were required to review toolkit prior to site visit.
Checklist of training activities 2.
Study overview • Study objectives • Introduction to research team members • Glossary of key terms • Project timeline 3.
Fall prevention service • Background information • Process algorithm • Stepwise processes for screening, medication review, sharing recommendations, patient education, and follow-up 4.
Tools • Cover fax form [ Figure S1] • High-risk medication algorithms [ Figure S2] • High-risk medication index [ Table S2] • Medication review checklist [ Figure S3] • Prescriber communication form [20] • Prescriber marketing flyer [ Figure S4] • Prescriber response form [20]  Acknowledgements LIVE WEBINAR A one-hour live webinar held on three alternating (morning/evening) dates, two weeks prior to live implementation. The webinar was recorded and disseminated to pharmacies to ensure training fidelity of future staff. Topics: 1.
Purpose of project 2.
Documentation and compensation processes

4.
Site visit expectations SITE VISIT A 45-to 60-minute site visit conducted by a member of the research team to meet with the pharmacy project champion and participating staff. Occurred during the first week of live implementation. Brief orientation 4.
Practice case and review of toolkit resources 5.
Q&A OPTIONAL TRAINING Two optional training opportunities: • STEADI: The Pharmacist's Role in Older Adult Fall Prevention [24] o An online continuing pharmacy education module for pharmacists and technicians. Developed by the American Pharmacists Association (APhA) and the Centers for Disease Control and Prevention. Free registration for APhA members and non-members. • Collaborative Approach to Falls Assessment and Prevention [25] o A one-day workshop held at North Carolina Association of Pharmacists Annual Meeting in September 2017. Provided comprehensive training on fall-risk assessment and prevention by an interdisciplinary team of pharmacists, an occupational therapist, and physical therapist. Free registration for meeting attendees.
STEP 2: LONGITUDINAL TRAINING QUICK TIPS WEBINARS Series of six 30-minute webinars held during the first six months of project. The webinars were recorded and disseminated to pharmacies to ensure training fidelity of future staff. News about project, falls research, state and national initiatives STEP 3: PROJECT COACHING A project coach was deployed from the investigative team to ensure fidelity of training among pharmacies and to provide technical support and feedback. The coach provided regular follow-up (i.e., every 1-2 weeks) by phone or email with pharmacy project champions for the first six months of the study. Follow-up continued to occur during the final three months of the project, but frequency was on an as-needed basis for each pharmacy.

Anticonvulsant Algorithm for Evaluating the Risk for Falls
The adverse effects associated with anticonvulsants may increase an individual's risk for falling. These agents cause sedation and dizziness resulting in the impairment of one's gait and balance and these effects are more pronounced in the elderly. Therefore, they should be used with caution in this population, especially when an individual is at increased risk for falls. In studies, anticonvulsants as a class have been found to increase the risk for falls and fracture. Even suggested alternatives may increase fall risk but are generally more tolerable and less likely to have altered pharmacokinetics in elderly patients compared to others in the class. Seizures may be controlled with lower or "subtherapeutic" doses of anticonvulsants in older patients. Preferred initial agent for all seizure types in the elderly Lamotrigine: start at 25mg/day, can increase by 25mg/ day every 2 weeks; max 100-300mg/ day Other alternatives as adjunct or for select seizure types Levetiracetam: start 500mg q12h, can increase by 500mg/ day every 2 weeks; max 1500mg q12h. Requires renal dose reduction. Gabapentin: start 300mg TID; max 600mg q8-12 hours. Requires renal dose reduction.

Discontinuing Therapy
Consider slowly tapering patients off the seizure medication if they meet the below criteria. (1) Seizure-free >2 years with subtherapeutic concentrations (2) Taking the medication for a long time and were placed on anticonvulsants prophylactically or for a few seizures, especially after stroke, neurosurgery or head trauma.

Changing Anticonvulsants
The new anticonvulsant should be within therapeutic concentration before tapering the old one. It may take up to a year to taper an anticonvulsant during discontinuation or crossovers.

Antidepressant Algorithm for Evaluating Risk for Falls
It is unclear how antidepressants increase an individuals risk for falling. Possible mechanisms include their potential to cause sedation and postural disturbances, although these effects vary with each agent and each person. Additionally, antidepressants may be indirectly associated with fall risk attributed to factors such as poor health status, depression, and weight loss. In studies, antidepressants have been found to increase the risk for falls and fracture. [8][9][10] General Considerations AVOID Paroxetine due to greater anticholinergic properties than other antidepressants, which may increase one's risk for falling. Anticholinergic adverse effects include sedation, confusion, dizziness, gait and balance problems, and weakness. AVOID Fluoxetine due to long-half life, which may be even more pronounced in the elderly; thereby increasing the risk for excessive CNS stimulation, sleep disturbances, and increasing agitation. AVOID Fluvoxamine due to drug interactions and availability of effective and safer agents. AVOID Nefazodone, while not directly linked to falls, is associated with hepatotoxicity and significant drug interactions, which limit its use.
Alternatives exist that are safer and as effective for treating depression. AVOID Isocarboxazid, Phenelzine, and Tranylcypromine should be avoided in the elderly due to their potential for toxicity and risk of drug-drug and drug-food interactions.

Suggested Alternatives
Citalopram: start 10mg daily; max 20mg/day Escitalopram: start 5mg daily; max 10mg/day Sertraline: start 25mg daily; max 200mg/day Duloxetine: avoid if GFR <30mL/min; start 30mg daily x2 weeks, increase to 60mg daily; max 120mg/day Venlafaxine: start 37.5mg (XR) or 25mg once or twice daily (IR); max 225mg/day Bupropion: start 37.5mg BID (IR), 100mg daily (SR), 150mg daily (XR); max 450mg/day (IR, XR), 400mg/day (SR) Buspirone: as adjunct start 7.5mg daily; max 7.5mg BID Educate patient on the potential for increased sedation, dizziness, and postural changes from the antidepressant. Monitor closely for adverse effects and falls. Consider switching agent if adverse effects are apparent. There is no one antidepressant or class considered the agent or class of choice in reducing one's risk for falls.
The association with antidepressants and fall risk has been attributed to all antidepressant agents.

Antihypertensive Algorithms for Evaluating the Risk for Falls
There is mixed evidence regarding association of antihypertensives and fall risk. Hypotension and orthostatic hypotension may contribute to fall risk, but evidence is also inconsistent in this aspect. There is no strong evidence indicating a specific class is preferred over others due to lower fall risk. However, with the possibility of orthostatic hypotension contributing to falls and strong evidence of cardiovascular benefits with specific classes of antihypertensives, some may be preferred over others. [11][12][13][14][15][16][17][18][19][20] Peripheral General Considerations AVOID Peripheral alpha-1 blockers for treatment of hypertension due to high risk of orthostatic hypotension and availability of alternative agents with superior risk-benefit profile.

AVOID
Centrally-acting medications due to high risk of adverse CNS effects, bradycardia, and orthostatic hypotension.
AVOID Immediate release nifedipine due to potential for hypotension

Suggested Alternatives
There is no clear evidence indicating that one medication or medication class should be preferred over others to reduce fall risk.
Selection of agents depends on patient's comorbid conditions. Generally, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, or thiazide diuretics would be preferred first-line agents for hypertension based on current guidelines.
Consider beta-blocker if patient has another compelling indication for its use or has resistant hypertension on preferred first-line agents. Selective beta-blockers (acebutolol, atenolol, betaxolol, bisoprolol, metoprolol, nebivolol) may have lower fall risk than non-selective beta blockers.
July 2017 Antipsychotic Algorithm for Evaluating the Risk for Falls Antipsychotics are thought to increase one's risk for falls due to their potential to cause significant adverse effects, including reduced alertness, impaired neuromuscular functioning, sedation, dizziness, postural hypotension, altered gait and balance, and extrapyramidal symptoms. In studies, antipsychotics have been found to increase one's risk for falls. Although atypical antipsychotics are generally bettertolerated overall and have less extrapyramidal effects, they are also associated with increased risk of falls. Avoid use of antipsychotics for treatment of conditions other than psychiatric conditions. [21][22][23][24][25][26][27][28] General Considerations AVOID Thioridazine due to potential for increased CNS and extrapyramidal adverse effects. This drug has a high incidence of sedation, orthostatic hypotension, and anticholinergic adverse effects, which may increase one's risk for falls.

AVOID
Chlorpromazine due to a high incidence of sedation, orthostatic hypotension, and anticholinergic adverse effects, which may increase one's risk for falls.

AVOID
Antipsychotics in elderly individuals with dementia which has been associated with increased mortality. If required use lowest dose for shortest duration needed.

Insomnia Behavioral Complications in Dementia
If low-dose antipsychotic being used, can discontinue without tapering.
Suggested Alternatives The following agents should only be used when all possible reasons for insomnia have been ruled out and behavioral approaches to sleep management (i.e., sleep hygiene) have been addressed. The lowest dose possible for a short-term period is recommended.
When discontinuing, consider tapering by 25% of original dose every 1-2 weeks.
Non-pharmacological interventions should be utilized before starting antipsychotic.
Risks and benefits of used should be carefully assessed.
If non-pharmacological approaches have failed and symptoms are severe, dangerous, and/ or cause significant distress to patient, low dose, less anticholinergic agent may be acceptable for shortest duration possible. Consider trial discontinuation within 4 months. For psychiatric conditions such as schizophrenia, schizoaffective disorder, bipolar disorder atypical antipsychotics with less anticholinergic properties may be preferred.
Suggested Alternatives Preferred drugs include: aripiprazole, olanzapine, quetiapine, and risperidone For management of acute psychiatric conditions such as delirium, address any contributing factors and utilize nonpharmacological interventions prior to medications. The previously noted medications may be used.

July 2017
July 2017 Benzodiazepine Algorithm for Evaluating the Risk for Falls The adverse effects associated with benzodiazepines may increase an individual's risk for falling. These agents are highly anticholinergic and cause sedation, confusion, dizziness, gait and balance problems, and weakness. These effects are more pronounced in the elderly. Therefore, they should be used with caution in this population, especially when an individual is at increased risk for falls. In studies, benzodiazepines as a class have been found to increase the risk for falls and fracture. 36 Consider decreasing dose by 25% every two weeks, and if possible, 12.5% reductions near end of taper and/ or planned drug-free days. If dosage form doesn't allow for 25% reduction, consider using 50% reduction initially and then drug-free days in the latter part of tapering.
If symptoms relapse, can consider maintaining current dose for 1-2 weeks then resume taper at slow rate.
All suggested alternatives may increase a patient's fall risk. One must determine the risk versus the benefit when selecting an alternative.

Refer to algorithm for antidepressants.
In addition, cognitive-behavioral therapy has been shown to be effective in the management of generalized anxiety disorder.
The following agents should only be used when all possible reasons for insomnia have been ruled out and behavioral approaches to sleep management (i.e., sleep hygiene) have been addressed. Consider re-evaluating need/ indication for the benzodiazepine due to potential for adverse events, especially falls. It is likely that the risk associated with these agents outweighs any benefit.

Suggested Alternatives
If benzodiazepine is required, lorazepam, oxazepam, temazepam may be preferred because metabolism is not affected by impaired liver function and they do not have active metabolites The lowest dose possible for a shortterm period is recommended.

July 2017
Opioid Algorithm for Evaluating the Risk for Falls The opioids likely increase an individual's risk for falling due to their potential for causing adverse effects, including reduced alertness, impaired neuromuscular function, sedation, dizziness, impaired cognition, and unsteadiness or impaired functioning. In studies, opioids/ narcotics have been found to increase one's risk for falls and fracture, although findings are inconsistent. [45][46][47][48][49] General Considerations AVOID Pentazocine/ naloxone as it causes CNS adverse effects, including confusion and hallucinations, which may increase one's risk for falls.

AVOID
Meperidine as it is not an effective oral analgesic in dosages commonly used and may have a higher risk of neurotoxicity, which may increase one's risk for falls.

Must weigh benefit of treating pain and increased risk of adverse effects and falls associated with opioids. If the opioid is continued, educate patient on the potential for increased sedation, dizziness, unsteadiness, and confusion, and closely monitor for the presence of these adverse effects.
Consider the following: Limit dose to 1 tablet at a time rather than 1-2 tablets.
Switch drug if adverse effects are apparent.

All suggested oral alternatives may increase a patient's fall risk.
One must determine the risk versus the benefit when selecting an alternative.

Sedative Hypnotic Algorithm for Evaluating the Risk for Falls
The adverse effects associated with sedative hypnotics may increase an individual's risk for falling. These agents are highly anticholinergic and cause sedation, confusion, dizziness, gait and balance problems, and weakness. These effects are more pronounced in the elderly. Therefore, they should be used with caution in this population, especially when an individual is at increased risk for falls. In studies, sedative hypnotics as a class have been found to increase the risk for falls and fracture. 50 Newer anticonvulsants lamotrigine, levetiracetam, and gabapentin are preferred in elderly patients due to improved safety and better tolerability.

Suggested Alternatives
The following agents should only be used when all possible reasons for insomnia have been ruled out and behavioral approaches to sleep management (i.e., sleep hygiene) have been addressed.

Suggested Alternatives
All suggested alternatives may increase a patient's fall risk. One must determine the risk versus the benefit when selecting an alternative.

Refer to algorithm for antidepressants.
May consider short term use of benzodiazepines (lorazepam, oxazepam, temazepam) for severe anxiety that has not responded to preferred agents.
Refer to algorithm for benzodiazepines.

July 2017
High-risk medication algorithm references

Tricyclic Antidepressant Algorithm for Evaluating the Risk for Falls
The tricyclic antidepressants are associated with high incidence of anticholinergic adverse effects, including reduced alertness, impaired neuromuscular functioning, sedation, dizziness, postural hypotension, altered gait and balance, and confusion. In studies, the tricyclic antidepressants have been associated with increased risk of falls. [55][56][57][58][59] Amitriptyline (Elavil) Imipramine (Tofranil) Amoxapine

Refer to algorithm for antidepressants
Must weigh benefit of treating pain with increased risk for falls.
Suggested Alternatives Duloxetine (Cymbalta): avoid if GFR <30 mL/ min, start 30mg daily; max 60mg/ day Venalfaxine (Effexor): start 37.5mg daily; max 225mg/ day Gabapentin: must be renally adjusted; start 50mg QHs, then 50mg q8h; max 300mg/day Lidocaine patch: apply to affected area for 12 hrs, then remove for 12 hrs Other topical lidocaine: usually applied 3-4 times daily Capsaicin topical: usually applied 2-4 times daily If a TCA is used and effectiveness has been demonstrated, ensure that the individual is on the lowest dose possible to control the pain and minimize adverse events.

Refer to algorithm for opioids
Suggested Alternatives The following agents should only be used when all possible reasons for insomnia have been ruled out and behavioral approaches to sleep management (i.e., sleep hygiene) have been addressed. The lowest dose possible for a short-term period is recommended.

Refer to algorithm for sedative-hypnotics
Suggested Alternatives Consider re-evaluating need/ indication for the TCA due to potential for adverse events, especially falls. It is likely that the risk associated with this agent outweighs any benefit.